Recommended Broker: Green Financial 1-800-877-8019  
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Premera Blue Cross Enrollment Instructions

To apply for coverage, complete the enrollment application and standard health questionnaire (SHQ).  One SHQ is required for each family member.  To prove Washington residency, you must include a photocopy of your drivers license (primary insured only) or a utility bill.  Mail all items to Green Financial. Do not send any money with the application.  Once approved, you will be billed on a monthly basis.

Applications must be received by the 19th of the month to be considered for an effective date for the first of the following month.

Enrollment Applications - (two forms are required):

Enrollment Application - PDF Form (94KB pdf, 6 pages)

Standard Health Questionnaire - PDF Form (242KB pdf, 23 pages)
Remember, one health questionnaire for each family member.  Although this form has 280 questions it is much easier to complete than it appears.  There are only 13 main sections (A through M). Answering "no" to any of the main questions allows you to skip the questions in that particular section.

If you prefer we can fax, mail, or e-mail these forms to you.  Either call us at 800-877-8019 or go to Home, Contact us and request. You'll need Acrobat Reader to display the PDF files.  If you don't have that program, you can download it free from Adobe.

Mail all forms to: Green Financial, P.O. Box 8036, Kirkland, WA 98034

Please call if any questions: 1-800-877-8019







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